Basic Information
| Provider Information | |||||||||
| NPI: | 1164973418 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOARD OF TRUSTEES OF MICHIGAN STATE UNIVERSITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD STE A109B | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178842976 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 FEE RD | ||||||||
| Address2: | B119 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488246410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173533070 | ||||||||
| FaxNumber: | 5174323603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2016 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | RUCKER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ENROLLMENT & PT ACCTS SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 5173558462 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.